Viewing by month: February 2011
February 24, 2011 | Posted By Liva Jacoby, PhD, MPH

The American Society of Clinical Oncology (ASCO) recently released a policy statement advocating that oncologists engage in candid conversations about prognosis and treatment options with patients suffering from advanced cancer. Published in the January issue of the Journal of Clinical Oncology, the article argues for individualized care entailing realistic conversations not only about prognosis and the risks and benefits of treatments, but also about the patient’s preferences, and his or her perspectives on quality of life. In fact, the authors state that “care intended to enhance patients’ quality of life should be a priority throughout the disease trajectory of advance cancer.” Importantly, the statement makes clear that the option of palliative care should be presented. As the basis for these new recommendations, the authors point to emerging evidence that such conversations take place late in the course of illness or not at all.  

In their discussions, the authors refer to studies showing the benefits of palliative care both for patients and their family caregivers. Yet, a preliminary analysis of over 5000 patient records from ASCO’s Quality Oncology Practice Initiative found that only 45% of patients had been enrolled in hospice care before they passed away and of these, one-third became enrolled within a week of their deaths.

The source for and the tenor of the recommendations are refreshing, not least in light of the recent politicization of end of life care conversations as part of the health care reform debates. The hope is now that oncologists will become trained to have such conversations and that they will persevere in the face of objections. At the end of the day the purpose of the recommendations is to reduce suffering among patients and their loved ones.

Please click the journal cover below to be taken to the full article.

February 15, 2011 | Posted By Sheila Otto, MA, BSN

I have a family member who is 88 yrs of age with acute on chronic problems ranging from diabetes to heart failure to debilitating shingles that have kept her bedbound over the last several weeks. She has gone from a spirited, independent survivor of loss (husband and two children), to someone who reluctantly moved into her daughter’s home and who is now in an ICU to manage her unstable blood sugars, new sepsis, and a blood clot. Her daughter is upset at her worsening condition and holds out hope that she will just “fight” a bit harder, try to do more for herself, and undergo rehab so she can return to her baseline.  When I suggested that maybe her mother was simply exhausted and nearing the end of her life, and that comfort care might be in her best interest, the daughter looked at me as if I had four heads. She responded that she didn’t have anyone else, that her mother was the last of the family.

As a critical care nurse, I saw many families respond this way. I must admit feeling sorry for her, a bit annoyed at what I perceive as her selfishness, and finally a bit cautious that my message was not well received. “This is not about you, but about her,” I wanted to say. Where is it written that each of us has the moral obligation to live out every last second, regardless of cost, pain, or suffering, so that our families can delay the inevitable? Modern medicine has provided multiple solutions to complex problems, yet in the end, we will all die. Why is talk of comfort care, without ICU admission and without pulling out all of the bells and whistles, still regarded as somehow shortchanging the patient (or is it the family)?  In a nation undergoing drastic health care changes which are controversially expensive, will we ever have the backbone to recognize that some resources are just not worth the enormous cost? There, I’ve said it. Note that I did not say my family member was not worth the money, but I did say that providing expensive high tech care for marginal to no benefit was not worth it.  As an ethicist, I know that “benefit” is defined by the patient/family, but as a realist, I also know that limits are needed for the public good. The same political voices that don’t want to expand coverage to all citizens because of the expense are also the first to discount my argument as discriminatory, anti-religious, or anti-individual. Guilty as charged.  At some point, we need to face the reality that care without limits costs all of us.

February 3, 2011 | Posted By Bruce D. White, DO, JD

About a year ago, the St. Petersburg Times reported that a Florida Circuit Court judge ordered that a 29-year-old mother of two, then 25-weeks pregnant, remain hospitalized involuntarily to protect the fetus. The newspaper quoted the judge as saying that the state had the authority “to ensure that children receive medical treatment which is necessary for the preservation of life and health.” (One early report may be found here.)

The reason the judge got involved was at the request of the woman’s attending physician who had asked the patient to quit smoking and to remain in bed to improve the odds for an improved outcome at delivery. The woman was dissatisfied with the care and requested to go elsewhere for treatment. The court intervened at the physician’s request with support from a state attorney. Unfortunately, the mother delivered a stillborn child a few days later.

In this case, the doctor, the state attorney, and the judge acted improperly under the state’s child welfare statutes. On appeal to the Florida Circuit Court of Appeals for the 2d Circuit, Judge Nikki Clark wrote an opinion last August that favored the patient’s rights over the state’s interests. The court ruled that the pregnant woman has fundamental rights to privacy under the Florida constitution and that any state interference was subject to strict scrutiny. (Click here for more information on the ruling.)

BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.